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Unplanned Extubation: Appendix

Unplanned Extubation: AppendixOur data suggest that patients receiving an FI02 >0.40 are at high risk for respiratory failure after unplanned extubation, while those receiving an FI02 <0.40 can be safely observed after such an event.
Total ventilatory support before to unplanned extubation, estimated by We, was also significantly higher in the RI group other generic allegra. This parameter was shown previously to correlate with successful weaning from prolonged mechanical ventilation. From our data, it appears that patients with a We >7 L/min will likely require reintubation following unplanned extubation; however, a significant portion of those with an We <7 L/min do well without reintubation and should be observed.
Pre-extubation minute ventilation (total Ve) was not significantly different between the two groups, and all patients in the NRI group had a Ve >10 L/min prior to unplanned extubation. This is somewhat surprising as Ve <10 L/min has been well-studied as a criterion for planned discontinuation of mechanical ventilation. Also notable is that the duration of intubation did not differ significantly between the two groups. Based on the observed mean values of Ve , duration of intubation, and PEEP, a power analysis revealed that our study lacked sufficient patient numbers to detect significant differences between the two groups. Additionally, we may have failed to identify other predictive parameters because of our small sample size.
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Unplanned Extubation: Conclusion

Reintubation after unplanned extubation should not be considered mandatory. Our reintubation incidence of only 78 percent (18 of 23 events) supports this position, and other series have reported reintubation rates as low as 31 percent.2 Furthermore, one group noted that 90 percent of the self-extubated patients in their study could have had more timely weaning and extubation. These observations imply that unplanned extubation may be viewed as an opportunity to discontinue mechanical ventilation. However, little is published regarding guidelines that would assist in the decision to reintu-bate. Jayamanne and coworkers noted that multisystem failure, altered mental status, and the need for controlled mandatory ventilation are strongly associated with the need for reintubation, and Sessler et al reported several routinely available parameters that may predict the need for reintubation. However, the literature does not reveal any other guidelines for reintubation Here generic claritin. This probably reflects a reliance on the clinical and laboratory data that become available after extubation, ie, respiratory rate, heart rate, blood gas data. In waiting to accrue such information, however, the likelihood of emergency intubation increases, necessitating much closer observation of a patient after unplanned extubation. In theory, these problems could be averted by using pre-extubation criteria for reintubation. An awareness of such criteria may diminish the physician’s impulse to “automatically” reintubate a patient who may fare well without further ventilatory support.
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Unplanned Extubation: Discussion

Unplanned Extubation: DiscussionUnplanned extubation—self-extubation or accidental extubation—occurs with surprising frequency in mechanically ventilated patients. In our study, the incidence of unplanned extubation was 7 percent, similar to the 8.5 percent to 16 percent reported in other studies. Furthermore, unplanned extubation is difficult to prevent, as evidenced by the fact that 65 percent of our patients had been sedated within 4 h of extubation, and that at least 91 percent were restrained. Stauffer and coworkers observed that some patients extubated themselves repeatedly despite arm restraints and careful attention by the was respiratory failure associated with toxic ingestion (6 percent); furthermore, the primary reason for prolonged mechanical ventilation in this patient was nosocomial sepsis. Within the RI group, the most common cause of respiratory failure was pneumonia, cited as the primary diagnosis in 12 of the 18 patients (67 percent). All three patients with Pneumocystis carinii pneumonia required reintubation, as did eight of the nine patients with bacterial or atypical pneumonia. Allergy medications so However, the presence of pneumonia was not a predictor of reintubation (p=0.155).

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Unplanned Extubation: Results

During the study period, there were 319 mechanically ventilated patients in the MICU; 23 unplanned extubations occurred during the same period (7 percent of all ventilated patients). Of the 23 events, only 2 appeared to have been accidental extubations, while the remainder were most likely intentional (self-extubations). In all cases, important measures had been taken to prevent unplanned extubation; bilateral wrist restraints were in place at the time of extubation in 21 of the 23 cases. The remaining two patients most likely had wrist restraints, as is protocol in our ICU, but this was not specifically noted in the medical records. In 15 of the 23 cases (65 percent), the patients had received intravenous sedation within 4 h of extubation (Table 1).
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Unplanned Extubation: Methods

Unplanned Extubation: MethodsUnplanned extubation, self-extubation or accidental extubation, is a common occurrence in mechanically ventilated patients.* Although many patients require reintubation, 47 percent to 69 percent fare well without further ventilatory support. Because weaning parameters are often unavailable at the time of unplanned extubation, it would be useful to define routinely available pre-extubation respiratory and ventilatory parameters that predict which patients will require reintubation. In this study, we reviewed 23 cases of unplanned extubation from the Medical Intensive Care Unit (MICU) at the University of New Mexico Hospital. We compared pre-ex-tubation values of commonly obtained respiratory and ventilatory parameters from patients who remained extubated with the same parameters from those who ultimately required reintubation.
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